This abridged version of David Wilkins report for Relate and Men’s Health Forum explores why men are so much more reluctant than women to seek out help when relationship difficulties occur. Previous research by Relate, the UK’s leading relationship support organization, has shown that 53% of men believe that there is a stigma attached to getting help from an expert for relationship problems. However, 26% of men say they would use Relate if they knew they wouldn’t be judged.

The problem of men’s poorer help-seeking does not only apply to the use of formal services. A 2009 survey by Mind found that only 31% of men compared to 47% of women would talk to family members about their feelings if they were unhappy and only 29% of men compared to 53% of women would talk to friends. Men’s close friendships with other men are also believed to “drop away” after about the age of 30. In general men score lower than women on all established measures of social and community connectedness and they are also less likely to access health services, dental services, ophthalmic services and pharmacy, as well as GP surgeries. Men are also in a minority of those who use telephone advice and help lines provided by healthcare charities.

Main areas of conflict

In terms of relationships, the report highlights the work/life balance as one of the main areas of conflict. Men spend more of their time at work, travelling to and from work or spending nights away from home because of work commitments than women do. The friction caused by poor work-life balance and long hours spent away from the home is therefore likely (on balance) to manifest in different ways for men and women.

Financial difficulties are another key trigger. Men continue to be the primary breadwinner in the majority of male/female couple households that are bringing up children. This may explain why loss of employment appears to affect men’s sense of wellbeing more negatively than it does that of women. The same is true of continuing job insecurity. Furthermore, as many as one in seven men may develop depression within six months of being made redundant.

The birth of a baby is also recognized as a trigger for relationship problems. After a new birth, some men suffer a conflict between the desire to be as engaged as possible with the baby, and the feeling that they may not be as competent as their female partner. There is a similar conflict between the desire to spend time with the baby and the increased responsibility for supporting the family.

Disputes over childcare often center on the balance of responsibilities undertaken by the parents. Some women describe feelings of increased isolation and lack of support at this time. Men are more likely to identify the emergence of a tension between the demands of work (exacerbated by the increased financial pressures on the family) and the desire to be involved with their child. Some men also experience a feeling of being “pushed out” after the birth of a baby.

The cost of relationship conflict

Knowing how and when it seek help is important because all couples, including those whose relationship will endure for a lifetime, will experience at least some difficult times that seem to threaten the future of the relationship. Trends in divorce rates suggest that around 45% of marriages that took place in the first years of the present century will end in divorce. Among cohabiting couples, the rate of relationship breakdown is even higher. Only 61% of those couples who were cohabiting in 1991 were still together 10 years later (compared with 82% of those who were married).

There is a significant social cost resulting from relationship beakdown, which impacts the lives of individuals, families and communities. In the case of couples with children, men are very much more likely than women to become the “non-resident parent” when relationships break down. Indeed, children are living with their father in only one lone parent household in eight and the Millennium Cohort Study suggests that as many as four in ten children being brought up by their mothers have no contact with their fathers at all.

Relationship breakdown also has a significant financial cost. Ruth Sutherland, Chief Executive of Relate says : “Relationship breakdown and its wider ramifications cost the UK economy £44 billion last year, according to the Relationships Foundation. This is a cost that we cannot afford to bear now and into the future.”

The benefits of a stable, happy upbringing for children (and hence for society as a whole) are obvious, but stable relationships also benefit the adults involved. Both sexes enjoy better physical health when they are in long term relationships, with men benefiting even more than women. Similarly, evidence from many countries has demonstrated strongly and consistently that a stable, long-term relationship is among the most important predisposing factors for good mental health for both men and women. Again, this benefit seems more marked for men.

The consequences of male reluctance to seek help

As the report’s author David Wilkins quite rightly points out “It is easier to identify a problem than it is to understand why the problem exists” but the consequences of male reluctance to seek physical, emotional and psychological support are both measurable and disturbing.

• On average, life expectancy is over four years shorter for men.

• Men are proportionately more likely at all ages to suffer from almost all the major forms of disease and injury.

• Cancers that are not specific to one sex or the other for example are, on average, 60% more common in men.

• Men smoke more than women

• Men eat a less healthy diet and are more likely to be overweight (66% of men compared with 57% of women)

• Only 51% of eligible men take part in the NHS Bowel Cancer Screening Programme compared with 57% of eligible women, despite men’s higher risk of developing bowel cancer.

• Almost three quarters of people who kill themselves are men.

• 73% of adults who “go missing” from home are men.

• 90% of rough sleepers are men.

• Men are three times more likely than women to be alcohol dependent. Excessive use of alcohol in particular has been described by the Mental Heath Foundation as “self medication” for “low-lying mental health or mood problems” with men markedly more likely than women to use alcohol to “fit in socially”

• Men are more than twice as likely to use Class A drugs. In 1999, The Samaritans found that young men with identifiable signs of depression were 10 times more likely to say that they would turn to drugs as a means of coping with their problems than young men who were not depressed. Unsurprisingly, 79% of drug-related deaths occur in men.

• Men make up 94% of the prison population. (72% of male prisoners suffer from two or more mental disorders).

• Men have measurably lower access to the social support of friends, relatives and community.

• Men are more likely to suffer from personality disorders (5.4% of men compared to 3.4% of women).

• Boys are performing less well than girls at all levels of education and over 80% of children permanently excluded from school are boys.

• Boys are 4 times more likely to be diagnosed as having a behavioural, emotional or social difficulty.

Healthcare professionals don’t pick up on the warning signs

Seeking help is particularly important for men because they can otherwise find themselves progressing through a predicable series of attempted coping strategies, each doomed to failure and each more destructive than the one before. They attempt to “numb” the pain (through alcohol or drugs for example) before trying to find a means of “escape” and, in some cases, ultimately reaching a point where they may be in danger of physically harming themselves or other people.

This latter point is an important one and some commentators have argued that “acting out” in general and “anger attacks” in particular may be a manifestation of distress in some men. The problem is that such “symptoms” almost inevitably militate against a sympathetic response from health professionals and other agencies, or even from family and friends. Mind’s 2009 report on men’s mental health, ‘Get it off your Chest’, suggests that it is: “essential that health professionals recognise when aggressive or violent behaviour is a potential indicator of mental distress and that this is reflected in the principles of diagnosis. This should help men get the right treatment at the right time instead of allowing mental health problems to deteriorate through not being treated.”

Living up to cultural stereotypes

One of the most common explanations for the male reluctance to seek help hinges on “socialization”, the idea that most men learn in boyhood to conform (to a greater or lesser extent) to a cultural stereotype that, among other things, does not easily allow the admission of vulnerability. The Samaritans important recent study of suicide risk among men in their mid years suggests for example, that many men, especially working class men: “compare themselves against a masculine ‘gold standard’ which prizes power, control and invincibility. When men believe they are not meeting this standard, they feel a sense of shame and defeat.”

Certainly few would dispute that boys in our culture are often encouraged to minimise the expression of hurt (“big boys don’t cry”). It is probably also true that boys are allowed greater leeway in the expression of externalised emotions like aggression, competitiveness and anger, which are associated with the idea of achieving and maintaining power.

Qualitative research has suggested that this view of the world has a direct impact on help-seeking behaviour for individual men: “It was apparent that to many participants to (be seen to) endure pain and to be ‘‘strong and silent’’ about ‘trivial’ symptoms, and especially about mental health or emotional problems, was a key practice of masculinity. As one focus group participant points out “My daughter can burst into tears and that’s OK. My son can’t because that’s not OK. That hasn’t changed and I’m not sure that it ever will”

The psychotherapist, Philip Hodson suggests that “It has indeed been difficult for 21st century men to adapt to a world where their natural anxieties are no longer masked by the universal subservience of women. Nor have they adjusted well to an economy that ignores brute strength in favour of brains and the utility of emotional intelligence.”

In simplest terms, it is suggested that men and women have developed different behaviour patterns because the behaviours that conferred evolutionary advantage differed between the sexes. These behavioural differences are sometimes said to be “hard-wired” into the brain and are believed to be observable from the very first days of life. Proponents of these genetic theories of gender difference suggest that men and women may be predisposed to hold different perspectives on relationships, to experience different forms of emotional distress and to exhibit different coping strategies

However as the academic psychologist, Christopher Kilmartin, the pioneer of “men’s studies”, and author of The Masculine Self, points out: “It has become scientifically indefensible to claim that either biological or social forces are solely responsible for gender behaviour.” Although help-seeking behaviours do differ between men and women and men and women tend to differ in their responses to emotional and psychological difficulties, in one sense, the explanations for these differences are unimportant. What matters is that the differences are there and that this has implications for people’s relationships and the way that couples use support services.

Its hard to talk

Two different Relate Focus Groups found that men find it much more difficult to talk about sex than women. One counsellor suggested that “Sometimes the driving force for men is ‘if I agree to go to Relate we will have better communication and then I will have more sex.” Both men and women commonly expressed the view that men found it more difficult within couples to talk about their emotions. In this context, the prevailing view was that men were more likely to “bottle things up”. Women believed that they needed actively to encourage their partners to talk about relationship problems. Interestingly, men were more likely to report arguments as a positive experience because arguments “were times when they could convey their real feelings”.

Researchers also observed that men tended to be less willing than women be open about their relationships during research interviews. This paralleled a view more commonly expressed by men when talking about their personal experiences, that they preferred to deal with their relationship problems privately. Men were also more likely to say that they found it difficult to discuss relationships with family and friends. Conversely, women spoke positively about the support they had received from family and friends. These findings echo the research in other fields that we discussed earlier, which identifies men as tending to have fewer intimate friendships than women and less access to other forms of social support.

The ‘sort it out’ approach

Although more men do seem to be accessing relationship counselling services, they appear to use the services less effectively than women. For example men are more likely to have unrealistic expectations of what can be achieved in counselling; are more likely to struggle to express their feelings; and appear less sensitive to difficulties in the relationship. Insights generated from two focus groups with Relate counsellors found that men have a tendency to want to “solve problems” whilst women want to discuss change and understand why things have happened. This desire to “solve problems” can often result in unrealistic expectations of counselling by men.

Men are more likely to seek practical “solutions” to their problems. One possible explanation suggested by participants was that men approach problems in this way because they tend to be less “in touch” with their emotions. It was believed that this was often where they needed help. A couple of the counsellors however, speculated that there might sometimes be advantages in this more “male” approach. In the context of discussing whether occasionally women might tend to get stuck in the emotional detail, one counsellor said: “Women don’t always go for the “solution-focused”, which men do. Once a man’s decided he’s going to change it, they are linear about it. They clear the debris and they sort it out.” Others felt that in some circumstances for some men (those who were reluctant participants, or those who were uncomfortable with talking about themselves), it was worth adapting somewhat to this way of looking at things

If we can’t change the cultural beliefs that inhibit men from seeking and accepting help, then we must change the way help is accessed and provided.

If it is accepted that men find it more difficult to admit to vulnerability for example, it doesn’t matter greatly whether that is for genetic or cultural reasons, or some combination of the two. The crucial thing is to recognise is that it is then bound to be problematic that the acknowledgement of vulnerability is often a pre-requisite of securing help.

Clearly, it is not possible to change men’s attitudes and behaviours (at least in the short term) but we have seen from other areas of service provision that better uptake of services by men can be achieved by adapting the way services are provided and marketed. Furthermore, if men and women do exhibit broadly different responses to emotional distress, it may well be that services need to think about whether men and women would sometimes benefit from different approaches in the relationship information, education and counselling that they are offered.

There is an approach to addressing relationship problems that fits very well with some men – perhaps particularly with men who may have most difficulty with more discursive, exploratory models of counselling. This approach is “solution-focused” and may need some adaptation of present provision but nevertheless it holds promise for better engagement of some men. Alternative forms of provision may be capable of improving the “reach” of relationship support services in respect of men. There is some evidence in favour of helplines but the same might apply to online models, which are not explored in this report.

The Main Recommendations of the Report

• The Department of Health, through the Improving Access to Psychological Therapies programme, should pilot new ways of engaging men to increase their participation in psychological therapies such as couple therapy for depression.

• Relationship support providers should explore less formal approaches torelationship support such as Relationship Coaching, which could make use of a more “practical” solution-focused approach to meet the needs of men in accessing relationship support.

• Relationship support providers should explore ways to take services out of traditional counselling settings and delivering them online and in communitysettings and workplaces. Providers should also explore ways of extending opening hours so that access to services is more flexible.

• Relationship support providers should experiment with ways to market their services directly to men, using “male-friendly” language and imagery.

• Relationship support providers should capture and publish their data in a gender-disaggregated form. This should include uptake, exit, evaluation and outcome data. The data should be used to support continuous improvement, including ensuring that services are better tailored to meet the needs of men.

• Relationship support providers should recognise the importance of third parties such as partners, relatives, friends and employers in encouraging men to access relationship support. They should experiment with ways of communicating with these audiences as an alternative way of reaching men. This could include partnerships with employers or marketing materials targeting partners.

• Further research is needed to understand better how and why men access (and don’t access) relationship support services.

About Relate Relate is the UK’s leading relationship support organisation, serving more than one million people through information, support and counselling. Our vision is a world where strong and healthy relationships are actively promoted as the basis of a thriving society and our mission is to develop and support healthy relationships by:

• Helping couples, families and individuals to make relationships work better

• Delivering inclusive, high-quality services that are relevant at every stage of life

• Helping both the public and policymakers improve their understanding of relationships and what makes them flourish

Everyone can access Relate services through a growing range of channels: face to face, online, on the phone and via email. Visit: www.relate.org.uk for more information.

About the Men’s Health Forum The Men’s Health Forum (MHF) is the only national organisation campaigning for better health for men and boys. It aims to be the centre of excellence for men’s health policy and practice, and to provide an independent and authoritative voice for male health in England and Wales. The MHF’s vision is a future in which all boys and men have an equal opportunity to attain the highest possible level of health and wellbeing. The MHF provides consultancy and training to organisations seeking to improve their services to men, and encourages research into the most important issues affecting male health. It also seeks to engage with the health policy agenda at local and national level. The MHF also tries to draw public attention to the key issues in male health and to encourage men and boys to take look after their own health.

Each June, the MHF runs National Men’s Health Week. It also manages malehealth.co.uk, the world’s most widely used male-specific health website. The MHF is currently leading an innovative and important five year project to develop a programme of initiatives aimed at improving male health in the London boroughs of Lambeth and Southwark

About the Author David Wilkins David Wilkins has worked for the Men’s Health Forum since 2002. He was responsible for the MHF’s overarching policy document ‘Getting It Sorted’ and has written policy papers on several specific aspects of male health, including men’s mental health; men’s sexual health; male obesity; and cancer in men. In recent years he has edited the Gender and Access to Health Services Study for the Department of Health and, with Erick Savoye, Men’s health around the world: a review of policy and progress across 11 countries. In 2009 David wrote Untold Problems: a review of the essential issues in the mental health of men and boys for the National Mental Health Development Unit (NMHDU). A second report for NMDHU, Delivering Male: Effective practice in male mental health, co-written with Mariam Kemple, was published in 2011. David has managed a number of practical projects aimed at improving men’s physical and mental health, both for the Men’s Health Forum and in the NHS. Most recently, for example, he led a three year project, funded by the Department of Health, which aimed to help redress the imbalance in uptake between men and women in the National Bowel Cancer Screening Programme. David writes frequently on men’s health issues and represents the “men’s health interest” on a number of national and regional policy development bodies.David was a community worker for several years. Immediately prior to his present appointment he worked for 11 years in the NHS, for the last three years of which he was a Lecturer/Practitioner in Health Promotion on a joint appointment with a local university. David lives in North Dorset with his wife and son.